Country Medicine

Idaho debates the doctor shortage

"It's so important not to get distracted," said Dr. Richard Paris, as he performed the first of many examinations for the day. Quiet fell as Paris surveyed the Cessna parked outside the Hailey hanger: It was the silence of careful concentration.

Paris probed the landing gear. He poked the underside of the wings, filling a vial with clear liquid. He studied the substance then proclaimed the fuel free from contaminants.

Paris surveyed the early September weather patterns sweeping through the Wood River Valley with the dedicated attention you'd expect from a family doctor named the 2005 Physician of the Year by the American Academy of Family Physicians. But Paris didn't mention this or other accolades. He'd rather talk about what his patients give him.

"Right now I have tons of kids that are graduating from high school that I delivered. And now, I see them doing college physicals. I knew them as babies. And their parents say, 'Yes, [Dr. Paris] was the first person who saw you.' The pleasant surprise is how great that would feel over the years."

It's something few people get to experience: Not many serve generations of families and treat patients "from the cradle to the grave," as Paris likes to say. Even fewer prepare to make their rounds by checking the fluid levels of a small engine aircraft.

Leila Ramella Rader

While medical officials, researchers and policymakers went about debating how best to boost the number of physicians in Idaho during the last legislative session, Paris was taking care of his usual business: pulling long hours and triple-duty as a physician, pilot and educator in order to deliver medical care to Idaho's remote and underserved patients.

Lawmakers want to see more doctors like Paris treating Idaho patients. The rarity of the rural family physician hurts not just remote country dwellers, but everyone who sets foot in Idaho, practitioners say. As part of lawmakers' efforts to boost the state's doctor to patient ratio, they're digging into research that could help remedy Idaho's physician shortage. That research points toward a number of educational options that could help attract doctors to the state and push some to consider the feasibility of an Idaho medical school. But physicians say it takes more than a medical school to rear the Idaho doctor. It takes a combination of intellect, dedication to service and a thirst for adventure to leave metropolitan medical hubs and the lucrative careers that come with them to open practice in a largely remote state. And that will to serve cannot be taught in any classroom.
UNDERSERVED IDAHO

"I think most people who go to a rural area [go] with the idea that they'd like to serve an underserved community, which most of the rural areas in Idaho are," said Dr. Jennifer Petrie, a faculty member at the Boise-based Family Medicine Residency of Idaho.

Thirty-five of Idaho's 44 counties have federal designation as Medically Underserved Areas and/or have medically underserved populations, designations pointing to a shortage of medical services or a population's inability to access heath care.

The number of doctors willing to serve
in these areas remains in short supply: Idaho's physician-per-patient ratio ranks last in the country.

The American Medical Association reported in 2002 that Idahoans had access to only 1.6 medical doctors per 1,000 residents. Massachusetts topped the rankings that year with 4.3 physicians per 1,000 residents. That state has since lost that title to Delaware in 2005. But Idaho still hangs at the bottom of the list—a last place that prompted lawmakers to begin studying solutions to the shortage that is expected to worsen as scores of Idaho physicians near retirement.

Debate about the creation of a more accessible and affordable health-care system remains a cornerstone in this year's presidential debates. But Pouliot said that even if all Idahoans had health insurance, many would still have a tough time accessing medical care.

"Even here in Boise, it is not easy to find a physician, especially if you're on Medicaid or Medicare," she said.

But when policymakers speak of the need to recruit Idaho doctors, they mostly speak of the shortage in the state's remote areas. In places where people are separated from the nearest medical services by more than just a few miles, patients need access to doctors who can deal with just about everything.

IN NEED OF A RARE BREED

"We are a rural state, and physicians want to go to a place where they can be successful and make money," said Sen. Dean Cameron, a Rupert Republican and member of the Legislative Medical Education Interim Committee, a working group charged with studying access to medical education in Idaho.

"Unless you're a rural person to begin with, you're not going to land in Rupert," Cameron said of the myriad of challenges that keep the much-needed family physicians from planting roots in Idaho.

The authors of at least one study point to one explanation limiting the number of doctors willing to open practices in Idaho: They're a rare breed.

"At the core is service," said Dr. David Schmitz, the associate director of rural family medicine at FMRI, of the motivation that drives family physicians to practice in Idaho, especially in the remote regions that dominate the state's landscape.

"I think it takes some guts. It takes some dedication."

Paris' Cessna 210 passed another routine pre-flight checkup and the doctor settled into the cockpit. With an OK from air traffic control, Paris steered the six-passenger plane down the lonely Hailey airstrip. The thin shell of the Cessna shook as it rolled toward take-off. After a bouncy acceleration, Paris was air borne. He pointed the plane toward Challis and assumed his position as the country doctor in flight.

Carissa Wolf

Haileys Dr. Richard Paris readies his plane for a commute to Challis. Paris regularly commutes by plane to Challis and Stanley in order to reach rural patients.

"On a nice blue-sky day like today,
it's a very efficient flight and a very inefficient drive."

Paris is indeed a rarity: The flying doctor possesses a unique blend of maverick smarts, altruistic compassion and a yearning for adventure.

While the sometimes lone doctor in the Idaho sky keeps his eye on the vast skyline with weekly flights to underserved areas, state officials look at a range of initiatives to boost the number of doctors to willing to trek the rugged backcountry or simply to set up practice in one of Idaho's underserved towns.

LEGISLATING A REMEDY

Lawmakers and researchers are considering everything from a state medical school to more residency programs as possible remedies to Idaho's doctor shortage.

A recent study commissioned by the Idaho State Legislature identified a number of feasible options that could help both train and retain doctors. Among the recommendations of the 2007 Medical Education Study Final Report is a push to expand medical education options. The study, submitted by MGT of America, a Florida-based consulting firm, examined the feasibility of different medical education models, including the expansion of residency programs, boosting the number of seats held for Idaho students at out-of-state universities and the creation of an in-state medical school. Each of the models earned a recommendation, but the latter kicked up the debate between policymakers and pundits, who largely criticized the development of a medical school as an overpriced pipe dream.

"I read an editorial today saying that the governor wants to build a medical school," said Idaho Gov. C.L. "Butch" Otter's spokesman, Jon Hanian. "He has never said that we're going to propose a medical school. He's said that needs to be one of the options that needs to be part of the debate."

Otter recently told a committee investigating solutions to the shortfall that the partnership between Idaho and the University of Washington—which admits Idaho students to the medical school for in-state tuition—has not created enough Idaho doctors to ease the shortage. Otter said the Washington program envisioned more than 30 years ago can't keep pace with demands.

"A lot has changed since the early '70s," Hanian said. "And we need to make some adjustments to make sure that we're getting the most for the amount of money we're putting into the program."

Idaho retains only about one-half of the 20 students who enter the University of Washington program each year. Idaho has a similar partnership with the University of Utah, which admits eight Idaho students annually who then pay in-state tuition.

Medical associations have also set their sights on updating the state's medical education program. They're mostly pushing to expand student opportunities through lobbying efforts, political clout and collaboration with colleges.

The IMA passed a resolution in August outlining the association's support for expanded medical training programs in the state. The resolution calls for doubling the number seats available to Idaho students at the University of Washington and University of Utah medical schools. The resolution also supports the expansion of residency programs, plans also backed by the MGT study.

"The support and expansion of our residency program is a high priority for IMA," Pouliot said. "Residency programs also give you the best bang for your buck."

Studies also show that physicians tend to establish practices near their residency programs. Fifty-four percent of the graduates of the Family Medicine Residency of Idaho program practice in Idaho. The majority of those physicians practice in rural areas, according to FMRI.

The IMA resolution also confirmed the commitment to creating an Idaho-based four-year medical program. But a four-year medical program does not necessarily mean building a traditional medical school from the ground up, Pouliot said. The MGT report examined the feasibility of different medical education models, including telemedicine, which uses different technologies to access clinical experiences, networking and mentoring.

An Idaho-based medical school, supporters argue, could help train and retain Idaho doctors close to home. But some physicians and researchers say medical schools don't birth the Idaho doctor. They believe rural doctors are born from a desire to serve and must be nurtured long before they enter medical school.

IT TAKES MORE THAN A
MEDICAL SCHOOL

The American Medical Student Association motto states, "It takes more than medical school to make a physician." Many Idaho physicians echo that adage.

"For me, teaching medicine and rural family medicine is about keeping it real. How can we take these young people and help them grow?" Schmitz said. "They already have the motivation to want to take care of people, to work hard, to be able to provide a broad scope of services, which is a challenging job—to be able to do all these different things. How do we encourage them to do it and to be happy doing it?"

Schmitz and Ed Baker, director of the Center for Health Policy at Boise State, believe family doctors possess innate, if not psychological, qualities drawing them to the field. The two are currently co-authoring a study examining the personality characteristics of family physicians. Schmitz thinks the study could help medical schools and practices recruit and retain more primary-care doctors by getting into the heads of practicing family physicians.

"What makes these doctors tick?" Schmitz said of the research's line of questioning. "Is there something identifiable? Are there characteristics that we can look to in regard to family physicians and being able to understand why they do so much and why they're willing to work hard and perhaps make less money than their physician peers, stick it out in sometimes stressful days and nights and still love what they do?"

The researchers are still in the beginning stages of their study, but experience tells Schmitz that family doctors indeed posses certain qualities that can't be taught in medical school.

"I see in the character of the students we interview for our program and the residents we have here for three years that there's just a really strong link to service," Schmitz said. "These folks are just dedicated. They want to serve and they just want to learn what they need to learn to be able to provide quality care."

SELL IDAHO

A sign next to the reception desk at the Challis Area Health Center reads, "We provide basic emergency services to the surrounding areas in addition to caring for regularly scheduled patients. We may need to contact you to reschedule your appointment due to an emergency."

Two expecting mothers, a man suffering from late-stage cancer and a patient with a shoulder injury are among those who passed the sign during one of Paris' shifts at the clinic. Around noon, the emergency came. An elderly man came to the clinic with symptoms of a cardiac problem. Between Paris, physician assistant Ken Hyatt and the small health center staff, the patient received constant medical attention for almost three hours before boarding a St. Luke's Regional Medical Center helicopter for the nearly one-hour flight to Boise.

"I wish I could put a Life Flight marketing sign next to every lottery machine in this town. Because if you're betting on your money, you're going to get a better return for your dollar with the Life Fight membership," Challis health center administrator Kate Taylor said as the patient was loaded on the helicopter by a medical flight team wearing blue jumpsuits.

The Challis health center serves as the sole emergency room for tourists and residents in the region surrounded by the Frank Church River of No Return Wilderness Area, the Sawtooths to the south and Mt. Borah to the east. The center treats everyone from farmers to mine workers and babies to thrill-seeking tourists. The patient diversity and the clinic's location put a host of demands on the staff.

The genesis of the clinic speaks to the demand for rural doctors by those who don't call the area home. The story of the origin of the Challis medical center rests mostly in oral history, but staffers recall that it started with a snake bite.

An East Coast family was traveling in the remote Custer County terrain in 1975 when one of their kids came across a snake, then felt a bite. The family rushed to find a doctor nearby but found no one. The child survived. But the futile search for a nearby medical clinic prompted the family to lobby the DuPont Foundation for funds to build a medical clinic.

Physicians and researchers agree that everyone could suffer when the closest doctor remains a snow storm or long, winding drive away.

"Let's say you decide to go river rafting or you decide to go up and enjoy a vacation in Sandpoint," Schmitz explained. "Anyone driving up Highway 95 could be in a motor vehicle accident and end up in an emergency room. We want to make sure you have a well-trained physician to take care of the trauma and transport you or be able to stabilize you. And the fact is, more likely that not, that doctor is going to be a family physician."

The FMRI fills this need with a rural-track program emphasizing a broad-based residency experience in rural settings. But the FMRI program has only a handful of seats, graduating 221 physicians since 1975.

But physicians point to a host of other barriers standing between the medical school graduate and a practice in Idaho. The doctor shortage is felt far beyond the state, but physicians and medical officials say that Idaho faces unique challenges when it comes to recruiting new physicians.

"Idaho is different. And Idaho is different in a couple of ways: It's not only rural, but it's isolated," Schmitz said.

"The job, I would argue, is more demanding than other specialties, especially in rural medicine when everybody needs you and you're the only show in town," Petrie said.

When you're the only show in town, you've got to know a little bit of everything and have the confidence to be able to treat anything. The rural doc must be a medical Renaissance man or woman of sorts. And these Renaissance types remain an elusive breed.

A 2007 pilot study of the Idaho physician workforce found that Idaho primary doctors provide a broad scope of care and perform a range of procedures. And not all medical students want to provide that kind of comprehensive care.

"The buck stops with me. I have to take care of patients one way or another, and I have to figure it out," said Dr. Brian Fortuin, a Twin Falls-based internal medicine specialist who often does rounds in rural Idaho. Even Twin Falls is rural by metropolitan standards, without a neurosurgeon and a scarcity of other specialists.

"I have to have the mindset that I have to take care of things I'm not necessarily familiar with until I can get the patient the appropriate specialty care," Fortuin explained. "Not everyone is comfortable with doing that."

And the isolation that often comes with rural Idaho medicine greets more than just the doctor. New physicians often come with a spouse, and recruiters have to sell an Idaho job to an entire family.

"Physicians, by nature, are well-educated. Oftentimes, they have a spouse in tow who has a professional degree or is highly educated," Fortuin said. "The family has to be willing to live in a small town."

And that may mean limited job opportunities for the doctor's spouse. It could be difficult to sell a job in Arco to a husband or wife with an aerospace engineering degree, Fortuin said.

The Idaho State Office of Rural Health and Primary Care aims to help communities overcome some of the challenges that make Idaho a hard sell to would-be physicians. The office educates physician recruiters on how to market their communities to potential doctors. That includes informing administrators about resources—such as federal student loan repayment programs—that may make their community more marketable.

"What Idaho has going for it ... is lifestyle," said Laura Rowen, primary-care program manager with the Office of Rural Health.

But the requests for loan repayments outweigh the available funds, and new physicians typically have two or more job offers when they graduate residency.

The shortage stands in sharp contradiction to reports over the last two decades that predicted physicians would face a very different job market. A 1994 article in the Journal of the American Medical Association predicted a surplus of 165,000 physicians by 2000. That and other predictions helped put a halt on the expansion and creation of new medical schools. The United States stopped opening medical schools in the 1980s, thanks in part to the projected overabundance of doctors, and medical advocacy groups lobbied to restrict the supply of new physicians. But physicians are not standing in unemployment lines and various new reports predict a shortfall. A 2005 Council on Graduate Medical Education study predicts a shortage of 85,000 physicians by 2020 and recommends increasing the number of medical school graduates by 3,000 annually until 2015.

RX: BREAK THE STEREOTYPE

Competition and stereotypes about rural medicine make recruiting tough. Some medical students perceive the rural physician as an unhappy, gray-haired man who works too much, Schmitz said.

Part of that stereotype holds some truth. It's not unusual for the family physician to work long hours on call, delivering babies, overseeing patient hospital care and tending to a multitude of other responsibilities.

"It's more difficult to have a work/life balance for physicians in rural areas," Pouliot said. "The newer generation of physicians tends to seek more of that work/life balance."

The inability to find that balance left Petrie burned out after serving two and a half years as a family physician in St. Maries.

"I had partners, but I was the only one that could do C-sections, so I was on call 24/7 for two and a half years, and I can count on one hand the number of weekends I had off," Petrie said. "It just gets to be hard. And then trying to figure out how I could incorporate a family into the scenario ... It just didn't seem like it would be fair to a young family ... I think it would be harder to balance families and rural medicine because it can be so demanding. Medicine in general will take as much time as you let it have. You just feel like there is so much to do all the time when you're in an area that doesn't have a high ratio of physicians to patients," Petrie said.

Dr. Tim Brininger knows that demand well. Try getting Brininger on the telephone if you're not his patient. You might reach him via cell during his commute between his medical home base in Mountain Home and the Duck Valley Indian Reservation. But once he starts seeing patients, he works with the fervor of a medical student and the dedication of a doctor who knows that there are many patients in need and only one of him. He's completely booked on many days from 7:30 a.m. until 9 p.m. He doesn't have to make the commute or work the long hours. But he does it because if he doesn't, he knows no one else will. He discovered that when he started seeing expectant mothers from the Duck Valley Reservation at his Mountain Home practice. Some were in pre-term labor. Others had no clue how long they'd been pregnant.

"We realized that they literally had not had any pre-natal care," Brininger said.

Other stereotypes about the country doctor don't hold up, according to the findings of the 2007 Idaho Family Physician Rural Work Force Assessment Pilot Study. The report prepared for the Idaho Office of Rural Health and Primary Care looked at who goes into family medicine and what kind of work they do. It found more women are entering the field and family doctors perform a wide range of procedures with a high degree of satisfaction. Nearly 93 percent of rural family physicians reported a high level of satisfaction with their current practice, according to the study.

"If you decide to be a family physician and work in a rural Idaho area, we've got an awful lot of people who are happy role models," said Schmitz, who co-authored the study.

But doctors say would-be rural physicians will never see those happy role models if they don't have access to mentoring opportunities.

"I FOUND MY WAY HERE"

While he's in the air, Paris plays tour guide, pointing out Idaho's grand peaks: Mt. Borah, the Sawtooths, Castle Peak. Shortly after the plane cleared a pocket of turbulence, Paris turned the plane over to auto pilot and let go of the controls. Out came the camera. Paris took pictures of the pine-and-sage dotted ridges and the alpine lakes in the distance. He snapped photos and shared a story, recalling history, explaining weather patterns and geography. He's used to the role of teacher and tour guide.

Paris has helped turn a new generation of physicians onto serving rural and underserved Idahoans by opening his practice and the door of his cockpit to rounds of medical students from the University of Washington. The gesture helps build the next generation of country doctors with pilot licenses. He has even convinced some students who may have taken up practices outside of the state to stick around and set up in rural Idaho. Petrie was one of those students.

"It solidified my desire to be in rural Idaho," Petrie said of her six-month rotation under the guidance of Paris.

Petrie said she'd be in rural Idaho right now if she didn't have a young family in Boise and a mother who can babysit in Emmett.

"I would have gone to Hailey. I was very, very close to going to Hailey, but I had realized I was having my third child," Petrie explained in a telephone interview. "Otherwise, I'd be talking to you from Hailey right now."

Petrie said that she feels like she has an influence on rural medicine as a faculty member at the Family Medicine Residency of Idaho program. And despite the long hours and challenges of rural medicine, she hasn't given up the dream of returning to a rural practice.

"It's certainly the best kind of medicine that I have ever practiced," Petrie said of her work in St. Maries. "I hope to someday return to a position more like that when the kids are a little bit older."

Students' exposure to rural medicine through residency programs or medical school rotations remains vital to increasing the Idaho physician workforce. The MGT study recommended expanding such programs, and 100 percent of the respondents to the 2007 workforce study said they support educational opportunities for medical students and/or residents at their sites.

The experience is vital, Paris said, because so many students are primarily exposed to a metropolitan-centric perspective in school.

"You look at medical school education and see that the majority of the people that are at medical schools and stay there as teachers are attracted to that kind of environment. For example, at the University of Washington, there are many, many good faculty members who are advising students, who have never been outside of Seattle for their work environment. [They] will tell students, 'Oh, I don't think you can do [rural medicine],' or 'That's not really feasible this day and age ...' Comments like that leave students kind of confused about what the possibilities are."

Paris' love for rural medicine grew in part through the encouragement of his childhood mentor, Dr. Harry Wheeler, who was a close family friend and a country doctor. Paris went hunting with Wheeler and learned the importance of the primary care physician in people's lives. He also saw the viability of practicing medicine in a rural setting. But not all doctors begin their plans for a career in rural medicine during childhood under the guidance of a beloved country doctor. A combination of educational opportunity, exposure to rural life and a passion for the outdoors help guide many of Paris' counterparts to practices in Idaho and its rural enclaves.

Fortuin credits his passion for outdoor life and the agreeable climate for helping bring him to Idaho. But he said it took a rotation in rural South Carolina during medical school to turn him onto the idea of serving a remote population.

"I sort of found my way here," Fortuin says of his education and career that took him from Duke University to the rural South to the University of Washington and then Livingston, Mont., and finally Challis and Twin Falls.

It was a month-long residency rotation in Livingston that got Fortuin seriously thinking about practicing medicine in the West. The internal medicine physician that mentored Fortuin showed him that a small-town generalist could make a big difference and have a viable career.

"I saw that he was able to take care of a broad spectrum of diseases," Fortuin recalled. "And he had a wonderful practice, so that got me excited."

"You have to make [rural medicine] look feasible and give them the experience," Paris said. "Because otherwise you'll just have the people who are highly adventurous and they're going to figure it out on their own. But you can't count on that. There's not going to be enough of those folks who are going to buck the trend and go for it."

Physicians will tell you that, yes they became the family doctor in order to serve. A few will tell you that they became the Idaho family doctor to serve and ski and paddle and hike and bike. The Idaho outdoors lures some young professionals, and Paris and Fortuin admit that the mountains, snow and open spaces first attracted them to the state.

"I came here for a break to do some skiing, and I realized that I [had] to find a way to stay here," Paris said.

As Paris finished another day in Challis, he sat in a small, unassuming office. A stack of charts sat before him. Above, a Norman Rockwell poster hung on the wall. The print portrays a country doctor tending to a young patient: The nostalgic image shows the physician checking the imaginary heartbeat of the child's stuffed teddy bear. On this day, the Challis health center staff treated more than the patient's body.

Hyatt and Taylor entered the room. They discussed the day, which included a lunch break around 3 p.m.—a slice or two of pizza consumed while standing. They congregated in the office and reviewed cases, discussed treatment plans and updated each other on patient progress. They mostly pondered whether they did enough for one particular man.

The patient was near the end of his life, suffering from incurable cancer. Palliative care was all that modern medicine could offer. They spoke of the patient's desire to hasten death. Did he have the means to bring death on himself? Yes, they agreed. Would he do it? No, they agreed. And they talked about the family's worry that they had not done enough for their loved one.

Hyatt assured the family that they offered their father and husband the best care possible. Paris assured Hyatt he offered the best medicine in this case: He comforted a patient and his family.

Paris returned to the stack of charts and dictated notes into a tape recorder before Taylor drove him to the Challis airstrip. Paris repeated the pre-flight routine, and then turned the plane toward Hailey. In flight, Paris pointed to a draw south of Challis. Below, over a ridge and beyond view of the aircraft sat the homestead of one of his oldest patients: a near centenarian. Paris will likely help this patient through his death, delivering on his commitment to serve the people of rural Idaho from the cradle to the grave.